Preventing Food Allergies May Start in Infancy

Significant results for egg and peanut, but not fish or gluten

Action Points

Note that this large meta-analysis found that early introduction of potentially allergenic foods appears to be beneficial in infants.

Be aware the data was most compelling for the early introduction of peanuts and eggs.

Early introduction of certain allergenic foods to the infant diet reduces the risk of developing an allergy to that food, found a systematic review and meta-analysis conducted for the U.K. Food Standards Agency.

Published in the Journal of the American Medical Association, the results indicated with moderate certainty that early introduction of peanuts (from 4-11 months) diminished the risk of subsequent peanut allergy (risk ratio [RR] 0.29; 95% CI 0.11-0.74; based on two randomized clinical trials with 1,550 children) compared with later introduction.

"In an infant whose family usually consumes egg and peanut, we can be reasonably confident that delaying egg and peanut introduction increases the infant's risk for allergy to those foods," reported Robert J. Boyle, MD, PhD, of Imperial College London, and colleagues.

"As long as there is no eczema or other sign of food allergy, then it seems reasonable to introduce egg and peanut when other complementary (solid) foods are introduced to the infant diet," Boyle told MedPage Today.

In an accompanying editorial in JAMA, Matthew Greenhawt, MD, MBA, MSc, of Children's Hospital Colorado, wrote that "the rigorous, comprehensive meta-analysis ... is an important addition to the evidence regarding food allergy prevention."

He noted that the findings support the 2008 guidelines from the American Academy of Pediatrics that raised "serious questions about the benefit of delaying the introduction of solid foods that are thought to be highly allergenic," such as egg and peanut.

All data examined allergenic food introduction (i.e., milk, egg, fish, shellfish, tree nuts, wheat, peanuts, and soy) during an infant's first year and development of allergic or autoimmune disease -- such as type 1 diabetes mellitus, celiac disease, inflammatory bowel disease, and juvenile rheumatoid arthritis -- at any age. Other high-quality systematic reviews were also included in order to avoid duplicating existing work.

The systematic review found evidence that the timing of introduction of certain allergenic foods to the infant diet was linked to risk of allergic disease but not risk of autoimmune disease.

While evidence was statistically significant for eggs and peanuts, the researchers found low- to very low-certainty evidence that early fish introduction was associated with reduced allergic sensitization and rhinitis. Additionally, there was high-certainty evidence that the timing of gluten introduction was not associated with celiac disease risk, and the timing of allergenic food introduction was not associated with other outcomes, Boyle said.

"Not all findings were statistically significant when we excluded the studies at high risk of bias in sensitivity analyses," Boyle told MedPage Today. "It was surprising to see no relationship between timing of gluten introduction and risk of celiac disease, given the positive findings for egg and peanut. I think this tells us that early allergenic food introduction reduces risk of some, but not all forms of food allergy."

While these findings do provide food for thought on delaying allergens in the infant diet, the researchers noted that the results should not automatically lead to new recommendations to feed egg and peanut to all infants.

"The imprecise effect estimates, issues regarding indirectness, and inconclusive trial sequential analysis findings all need to be considered, together with a careful assessment of the safety and acceptability of early egg and peanut introduction in different populations," said Boyle.

Greenhawt echoed the idea of cautious interpretation, but believes the review offers key insights for preventing allergies. "Delay of introduction of these foods may be associated with some degree of potential harm, and early introduction of selected foods appears to have a well-defined benefit," he wrote.

"These important points should resonate with allergy specialists, primary care physicians, and other healthcare professionals who care for infants, as well as obstetricians caring for pregnant mothers, all of whom are important stakeholders in effectively conveying the message that guidance to delay allergen introduction is outdated."

Boyle reported receipt of consultancy fees from Imperial Consultants for the work. Other authors reported no relationships with industry.

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